Healthcare Provider Details

I. General information

NPI: 1700898822
Provider Name (Legal Business Name): POCATELLO CHILDREN & ADOLESCENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 HOSPITAL WAY BLDG F
POCATELLO ID
83201-5091
US

IV. Provider business mailing address

1151 HOSPITAL WAY BLDG F
POCATELLO ID
83201-5091
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-1443
  • Fax: 208-239-3434
Mailing address:
  • Phone: 208-232-1443
  • Fax: 208-239-3434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JESSICA PERRY
Title or Position: ADMINISTRATOR
Credential:
Phone: 208-236-9600